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Afghanistan - February 2008
The World Bank indicates that Afghanistan is on the verge of becoming a failed nation. Each of us is aware of the military and political events reported in our morning papers, but we are less cognizant of the struggles faced by the civilian population. The estimated 31 to 32 million Afghans are estimated to have rates of illiteracy between 70 and 90%. Everything is estimated, because the various governments have never had enough resources for censuses or services. Commerce is strained as the high rate of illiteracy makes it difficult to train workers that are needed for a skilled work force to create industry for good jobs. The absence of well paying jobs focuses most Afghans on keeping their families warm, sheltered, and fed. It is cold in Kabul this winter and many say that this is the coldest winter in memory. The period of this memory must be about 40 years since the average life expectancy is only 44. This hard statistic summarizes the end result of the deficiencies found in Afghanistan in 2008: food and water, basic shelter, education, health care, and personal safety. In addition, the deficiencies in the health care system extend to orthopedic care. Despite this, the Afghan Orthopedic Surgeons are supremely resilient and dedicated. Both WAKH and the Military Hospital are busy with orthopedic patients. While accurate statistics are not available the hospitals appear to have workloads comparable to that of US Level I Trauma Centers. Most of the fractures are due to road traffic accidents, falls, or violence. Due to the large numbers of fractures and the delayed presentation of patients many fractures are treated several weeks after the initial injury. There are many remote villages with few roads making it difficult to travel the mountainous terrain. We were told that as many as ten per cent of the patients use donkeys as part of their transportation to the hospital. As a result of the Russian occupation (war) between 1979 and 1989 the Afghan Orthopedists are masters of Ilizarov techniques and classic AO techniques, which were taught by Russian physicians during their stays. The absence of intraoperative fluoroscopy has prohibited further advances in other techniques of fracture fixation. The wars also produced expertise in amputation surgery, the result of the estimated 10 million mines placed within 4,000 minefields. Some mines still exist, and lower extremity amputees are frequently seen in Kabul. Orthopedic education has been and continues to be frustrated by the widespread destruction of libraries and lack of resources from this country's conflicts. 'Recent' texts have 1970's copyrights. Prior to SIGN, closed femoral fractures have been primarily managed by ORIF - plate fixation. In observing several of these surgeries the surgeons are facile with classic AO techniques, direct anatomic reductions and rigid interfragmentary fixation. Tibia fractures are to date treated nonoperatively, by plate fixation, and external fixation for the open tibial fractures. The introduction of SIGN at the public WAKH (Wazir Aga Kahn Hospital2) and the Military Hospital was enthusiastically received. Afghan Surgeons rapidly and proficiently adapted to intramedullary nailing. The surgeons are deft technicians and quickly learned SIGN with Lew and I being placed in the roles of operative assistants. The attention to detail and quest for surgical excellence by our hosts was inspiring. Toward the end of the visit at least two intramedullary nailings a day were performed. Despite the delivery of SIGN nails there are many other obstacles. Processes for sterilization and the inventory of fracture implants are restricted. Modern sterilization processors and operating room resources remain significant goals. Planning is underway for the Loma Linda project to help at WAKH and the US Military liaison to help at the Afghan Military Hospital. Accurate statistics regarding infection rates are not available; however both hospitals are working to achieve better understandings of their practices. There is a severe lack of implants. Imagine seeing about 8-10 patients with intertrochanteric hip fractures being managed non-operatively during morning rounds. But, simply providing implants will not 'cure' the problem since intraoperative fluoroscopy, or any form of intraoperative imaging is not available. Afghanistan has great promise. Because of the commitment of the surgeons, their skills, and their attitudes much can be accomplished. However, it is easy to forget this distant country and this passage written by Camus in the Plague speaks to the marginalization of what we do not see. "Figures floated across his memory, and he recalled that some thirty or so great plagues known to history had accounted for nearly a hundred million deaths. But what are a hundred million deaths? …. And since a dead man has no substance unless one had actually seen him dead, a hundred million corpses broadcast through history are no more than a puff of smoke in the imagination." (Camus) As physicians we see, and the use of SIGN gives us promise.
David Templeman MD |
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